Ninety-four patients admitted to Leicester Hospitals with acute cholangitis since 1977 were reviewed to coincide with the availability of endoscopic sphincterotomy (ES). Thirty-four were men and sixty were women, their mean age was 69.7 years and the median hospital stay was 20 days. There were 15 deaths (16 per cent) by 30 days in patients with significantly lower initial serum albumin levels (P less than 0.005) and significantly higher serum urea levels (P less than 0.05) than survivors. Eighty-two patients had common bile duct (CBD) calculi of whom 71 underwent early decompression of the biliary tree either surgically (28) or by ES(43). Early surgical decompression was associated with a significantly higher 30 day mortality (6/28) than early ES (2/43) (P less than 0.02) despite the fact that patients undergoing early ES were significantly older (P less than 0.02) and had significantly more medical risk factors (P less than 0.05). Of the 43 patients undergoing early ES 7 had had a previous cholecystectomy, 13 underwent subsequent elective cholecystectomy with no mortality and the remaining 23 had the gallbladder left in situ because of advanced age (mean age 79 years) and frailty. Only 2 of the 23 have since required cholecystectomy. We suggest that patients with acute cholangitis who do not rapidly respond to conservative treatment should undergo early ES with early surgery reserved for those who do not improve following ES. Elective cholecystectomy following successful ES can often be avoided in the elderly and frail.